Measuring Intravenous Cannulation Skills of Practical Nursing Students Using Rubber Mannequin Intravenous Training Arms

Transcription

1 MILITARY MEDICINE, 179, 11:1361, 2014 Measuring Intravenous Cannulation Skills of Practical Nursing Students Using Rubber Mannequin Intravenous Training Arms SFC Robert S. Jones, USA (Ret.)*; LTC Angela Simmons, AN USA ; SSG Gary L. Boykin Sr., USA (Ret.) ; David Stamper, EdD ; COL Jennifer C. Thompson, MC USA (Ret.) ABSTRACT This study examined the effectiveness of two training methods for peripheral intravenous (IV) cannulation; one using rubber mannequin IV training arms, and the other consisting of students performing the procedure on each other. Two hundred-sixty Phase II Army Practical Nursing students were randomized into two groups and trained to perform an IV cannulation procedure. All students watched a 12-minute training video covering standard IV placement procedures. Afterward, both groups practiced the procedure for an hour according to their assigned group. Students were then tested on IV placement in a live human arm using a 14-item testing instrument in three trials that were scored pass/fail. There was no difference in the groups performance of the IV procedure on the first attempt: 51.7% (n = 92) of the human arm group passed the test, and 48.3% (n = 86) of the rubber mannequin group passed the test (p = 0.074). These data suggest that using rubber mannequin IV arms for IV skills training may be just as effective as training students using traditional methods. In addition, using simulation provides an extra benefit of reducing risks associated with learning the procedure on a fellow student. *Army Medical Department Center & School, Department of Nursing Science, 3490 Forage Road, Fort Sam Houston, Texas Center for Nursing Science & Clinical Inquiry, Brooke Army, Medical Center, 3600 Roger Brooke Drive, Fort Sam Houston, Texas U.S. Army Research Laboratory, AMEDD, Field Element, 2377 Greeley Road, Fort Sam Houston, Texas Graduate Medical Education, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, Texas korlando VA Medical Center, 5201 Raymond Street, Orlando, Florida Preliminary data collected in this study was presented in a poster presentation during the Karen A. Rieder Federal Nursing Poster Session and Tri- Service Nursing Research Section at the 117th Annual Meeting of AMSUS that took place in San Antonio, Texas on November 8, The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense, the Veterans Health Administration, or the U.S. Government. doi: /MILMED-D INTRODUCTION Army Licensed Practical Nurses (LPNs) are expected to apply cognitive, psychomotor, and procedural skills in performing nursing duties whether during peace time in clinical environments or during combat in field environments. Their initial training and academic preparation for licensure is intense and extensive. Their skills and competencies are certified through Army mandated annual skills validation and sustainment training to remain qualified in their Military Occupational Specialty 68WM6, Army LPN. Intravenous (IV) cannulation is an essential skill that military nurses must possess to treat various types of patients, trauma or medical, and achieve fluid volume resuscitation in acutely or critically ill patients. Army LPNs are also required to meet National Emergency Medical Technician and combat medic standards, which include starting an IV to facilitate emergency fluid resuscitation on the battlefield or in a clinical setting when venous access is needed. 1,2 LPNs work alongside registered nurses in the military treatment facility providing care for patients in 24-hour inpatient settings. They are trained to recognize trends or changes in a patient s condition, including complications with IV sites such as infiltration, phlebitis, or infection. Hence it is paramount that these nurses are able to initiate and change IV sites to provide fluid therapy and prevent complications. Background Before being allowed to care for patients, those striving to be health care providers must develop certain skills necessary for providing safe, quality care. One of these skills is the ability to place and maintain an IV infusion. Initiating and managing IVs is required in all emergency situations. 3 Furthermore, starting IV therapy is considered to be one of the most effective ways a combat medic can prevent death on the battlefield. 4 The combat medic is the entry level care provider in the military setting and is often the first line of care on the battlefield. One of the skills that is taught and subsequently reinforced is the initiation of IV s. Although this is a common procedure, it is complex and can pose a risk for both patients and medics if not performed properly. 5 To apply for the Army s LPN course, prospective students should already have achieved the 68W (combat medic) Military Occupational Specialty. They are expected to be proficient in IV skills and demonstrate their competency through annual skills validation. 4 In addition, the student is expected to maintain his combat medic skills, including IV initiation and infusions, even after being accepted into the Army s LPN course. Like civilian nursing programs, Army LPN training programs have utilized various methods to teach IV cannulation MILITARY MEDICINE, Vol. 179, November

2 skills, but no standardized methods have been adopted Armywide. For example, there are five Phase II LPN training sites within the Army, where students receive didactic and clinical training to complete the requirements for the National Council Licensure Examination for Practical Nurses. Some training sites have students start IVs on each other in order to increase their proficiency and to provide more realistic training, whereas other training sites have incorporated the use of task trainers or other medical simulators (personal communication, Oct 2009, May 2013). Because of lack of funding, space, and other issues that accompany the purchase of task trainers such as rubber mannequin IV training arms or high-fidelity simulators, not all programs have incorporated simulation-based education. 6,7 Until recently, nursing programs across the country had not typically incorporated simulation throughout the curriculum; however, because of the increase in the number of students and decrease in both faculty and the inpatient population, most programs are turning to simulation. 8 Although simulation-based training allows students the opportunity to practice skills without the stress of caring for a live patient, there is a paucity of literature that compares different methods of simulation-based training There is a need to study the use of rubber mannequin IV arms in teaching IV cannulation skills using this population to validate its applicability as a standard training modality before performing the procedure on live patients. IV cannulation training has been very unstructured in both medical and nursing provider training. 11,12 According to Acharya et al, some medical residents are not trained on IV skills because training is moving toward a less hands-on approach whereby the resident relies more heavily on ancillary staff for certain procedures. 13 When students (medical and nursing) are taught IV cannulation, different strategies are employed including the use of oranges, plastic mannequins, high-fidelity simulators, or starting IVs on fellow students. Although these methods provide practice that serves to familiarize the student with the procedure and equipment needed, they offer significant variability and may cause undue stress on the student. 10 Furthermore, initiating and maintaining IV s is not a requirement for licensure from the Texas State Board of Nursing, which serves as the regulatory agency that provides initial licensure for all Army LPNs. 14 However, since combat medics and LPNs in the military are often the first line of medical/nursing care for soldiers on the battlefield, this skill is essential for their practice. Effectively training health care providers, including nurses and physicians, on IV initiation and maintenance has been a challenge discussed in the literature. As students, some registered nurses are trained on initiating IVs and maintaining the IV site using various methods including highfidelity computer-assisted simulation, mannequins, and the latex mannequin trainer arm. 9,10,15 Researchers have found that the majority of nursing programs enable students to achieve all nursing skills related to IV therapy except they do not allow them to insert the IV on a live patient. 15,16 Milliam 16 surveyed 138 nurses and nursing school faculty and found that schools in the 1980s taught nurses how to maintain IVs, manage central lines, and remove IVs, but they fell short of teaching nursing students how to initiate IVs. Nursing programs have progressed to teaching IV insertion, but there is no standardized instruction provided across all nursing programs. Some programs will provide IV education during the first clinical year before students taking care of patients, and some teach the skill in the last semester before graduation. 10,16 In general, there is a dearth of literature surrounding IV training with LPNs. Simulation provides a means for training in a less threatening environment in which students are not exposing patients to unnecessary pain and suffering. 8 Also, the learner has permission to fail in a way that isn t possible in the clinical setting, allowing the learner to gain needed expertise in a skill through practice and at a pace with which the learner is comfortable. Simulation appears to be widely accepted in medical school programs perhaps because of the need to train students on complicated assessments and procedures. Less has been published on the use of simulation to train on less complicated procedures such as starting IVs. Using a high fidelity virtual reality simulator, Loukas et al 8 conducted a study to examine whether simulation training enhanced the IV cannulation skills of medical students. They found that the skills of inexperienced students significantly increased after training using the simulator and similar results were found in other studies involving medical students. Those who participated in a clinical skills lab where IVs were inserted using mannequins reported a higher level of performance than students who started IVs on other students. 8,11,13 Similar results were found in studies conducted by Lund et al, and Acharya et al. However, these studies failed to demonstrate a statistically significant difference in the accuracy of initiating IVs in live patients; though, it was reported in these studies that students who were trained using simulation needed less preparation time to initiate IVs on patients, and they completed the procedure using proper technique significantly more often than the group that did not use simulation. 8,11,13 In addition, participants reported increased knowledge and self-confidence with IV cannulation. 8,10 A study conducted by Wilfong et al 10 with a group of registered nurses comparing the use of the virtual reality IV simulator with the traditional method where registered nursing students perform the procedure on each other found that the nurses who were trained with the simulator required fewer IV attempts than those in the group who trained by the traditional methods. Also, these nurses expressed increased confidence in their abilities to start IVs in the future regardless of the method they used for training. Yet, comparable to the studies involving medical students, this study did not examine the students IV success rates in the clinical setting when starting IVs on live patients. In addition, although 1362 MILITARY MEDICINE, Vol. 179, November 2014

3 results of the studies showed a difference in the number of attempts to start IVs of the students, that difference barely approached significance and had a medium effect size ( c 2 [1, N = 41] = 4.19, p = 0.041, j = 0.32). Although the use of simulation training has been shown to have a positive impact on the skills competency in health care professionals and students, the use of such mechanisms in training the Army Practical Nursing student population has not been previously examined. At present, Army LPN training on the placement and maintenance of IV lines consists of didactic instruction followed by either a session in which students practice the procedure on each other in supervised sessions with guidance from trained instructors, or alternatively, they may use rubber mannequin IV training arms to assess the student s proficiency in performing an IV cannulation. The Adult IV Training Arm (Laerdal Medical Corporation, Wappingers Falls, NY) is a task trainer specifically designed for teaching and practicing peripheral IV cannulation skills. 17 This device is a latex constructed mannequin arm composite replica of a human forearm and hand that has well-articulated veins throughout that contain rubberized tubing filled with water concentrated with red dye to imitate blood. This red-colored liquid is flushed through the arm s tubing system that is designed to replicate veins in a human arm that respond to venipuncture. 9,17 Despite these features, the arm does not possess certain human physical characteristics such as skin temperature, thickness, elasticity, and color as it relates to perfusion and changes in patient status or condition. The device is not currently being used as the standard for training and assessing students IV cannulation skills in the Army s LPN course. Using simulation or traditional methods for training IV cannulation skills have advantages and disadvantages; however, training IV cannulation on fellow students subjects the trainees to the discomfort associated with the procedure, as well as the inherent risk for infection associated with a break in skin integrity; both of these risks are avoided with the rubber mannequin IV training arm. 5 In addition, the two methods have not been compared to determine if one method is more effective than the other with regard to the translation of knowledge to practice among LPN students. If training and practicing IV cannulation using a rubber mannequin IV training arm is shown to be equivalent to training on fellow students, it may be possible to limit or eliminate the current practice in which students train by performing this procedure on each other. In addition, the rubber mannequin IV training arm may provide a cost-effective method for training and testing this important skill. We therefore conducted a prospective, randomized controlled study to determine if using the rubber mannequin IV training arm was equivalent to using a live student model to teach IV cannulation; additionally, we attempted to determine if the use of this type of simulation decreased fear and anxiety and increased student s preparedness in performing IV cannulation procedures. METHODS Study Participants Before conducting this study, the proposal was reviewed and approved by the Institutional Review Board at Brooke Army Medical Center. The study was conducted at the Army Practical Nurse training course (68WM6) at Fort Sam Houston, Texas. The study cohort was recruited from five classes attending training in two independent phases of the course. Students completed the first (didactic) phase of their training at Fort Sam Houston, and the second (clinical) phase of the course was conducted at the San Antonio Military Medical Center. During phase II, students received an informational briefing about the study in accordance with the experimental protocol at the beginning of the intravenous infusion training module. Two hundred-sixty practical nurse students elected to participate by signing an informed consent document acknowledging their acceptance into the study. All students had been previously trained on inserting IVs during their combat medic training as well as in Phase I of the 68WM6 course. Table I shows demographics of both groups. A Texas Instruments TI83 calculator random number generator function was used to assign students to one of two groups. Participants could be assigned to Group A (the control group) where they were paired with a fellow participant and instructed to practice performing IV placement on each other under the guidance of an instructor. Alternatively, participants could be assigned to the experimental group (Group B), paired with a fellow participant and instructed to use a rubber mannequin IV training arm to practice the procedure under instructor guidance. Procedures Before the training, students provided demographic information and completed a survey that included questions about prior medical and simulation experience to include prior experience initiating IVs in live patients. Participants then watched an Army Medical Department Center & School instructor-led video-recording narrated with step-by-step IV administration instructions. This method was intended to standardize the didactic instruction and avoid instructor biases; however, a live instructor was on hand to answer questions regarding the procedures. The instructional video lasted approximately 12 minutes, was projected under ambient lighting and was shown on a large screen facing forward of the classroom. Immediately following the instructional video, based on their randomization assignment, students were allowed to practice the IV procedure from start to finish for approximately 1 hour using either the human arm of a fellow student, or a rubber mannequin IV training arm. Afterward, students were tested on IV placement in a live human arm by a certified nursing instructor using a 14-item, three trials IV skills testing and scoring instrument. Students received either a pass or fail score for each trial completed. MILITARY MEDICINE, Vol. 179, November

4 Data Collection Procedures The IV skills testing/scoring instrument contained 14 testing tasks, of which the first nine sequential tasks were designated as critical for the students to complete to receive a passing performance score. The tasks were all extracted from the Training Circular checklist used during the combat medic training courses. 4 Successful performance of the procedure was measured by students obtaining blood in the flash chamber of the catheter followed by venous cannulation and injection of saline into the vein. Students who were unsuccessful after their first attempt of the IV procedure were allowed two additional attempts for a total of three trials. Testing was proctored by certified Army nursing instructors who completed an approved procedural testing checklist as the students performed each task. At no time did instructors coach or assist students during testing. Only unsafe acts during testing were addressed by the instructor. Students who participated in the training and testing phase of the study did not incur any adverse effects from the IV procedure performed on them by a fellow student. Immediately following the IV skills testing (whether they passed or failed), students returned to the classroom and were asked to complete a survey that was created by the researchers for the purpose of collecting data targeting the student s perceptions of the training they had received. The survey included four questions rated on a four-point Likert scale and an area at the end that allowed for additional comments concerning the training. The main focus of the survey was to inquire about the student s level of confidence in performing a peripheral intravenous cannulation procedure. Emphasis was also placed on collecting information regarding the student s perceptions of the training they had received and the effect it had on their IV skills performance. In constructing the questions on this particular survey, the researchers sought to obtain information from the students on whether or not the intended outcomes of the training had been met and whether they felt the training was useful for them. After initial training and testing, the students began the second phase of their training, which included an introduction to the clinical setting at San Antonio Military Medical Center. After approximately 90 days, students were reevaluated by a certified instructor on their ability to place an IV in a live patient. During the 90-day follow-up evaluation, students were allowed up to three attempts to achieve successful IV cannulation. This was the same as the method used to assess the students IV cannulation skills during the initial training. Following this phase of the training students also completed a 90-day follow-up four-point Likert scale survey assessing short-term training significance, perceived confidence and anxiety levels during the IV procedure, and the value of the IV training they had previously received. Congruent with the methods that were used in constructing the questions in the previous survey, researchers sought to provide a mechanism for capturing the student s perceptions of the usefulness of the training and whether or not it met the intended outcomes TABLE I. Participant Demographic Composition Group 1 (Human Arm) Group 2 (Mannequin Arm) Number Percent a Number Percent a Gender Male % 85 63% Female % 50 37% Total Number per Group 124 Mean Age and Standard Deviation (6.16) (6.47) Race/Ethnicity Caucasion % 83 61% African American % % Hispanic % % Native American 1 8% 1 7% Middle Eastern 2 1.6% 4 2.9% Asian 8 6.5% 8 5.9% Other 3 24% 5 3.7% Education GED 4 3.2% 4 3% High School 38 31% 30 22% Some College 67 54% 81 60% Associates 7 6% % Bachelors 8 6.5% % Military Enlistment Status Active Duty % % Reserve 68 55% % International 0 0% 1 0.7% a Percentages in this table does not always sum to 100% as a result of rounding. p Value 1364 MILITARY MEDICINE, Vol. 179, November 2014

5 FIGURE 1. Research design. the researchers had set. Figure 1 illustrates the research design used for this study. Data Analysis The data from all completed surveys were entered into a Microsoft Excel spreadsheet following each data collection session. After all data were received, it was entered into the Statistical Package for the Social Sciences software (SPSS, Version 18) for analysis. The independent variables were teaching modality (live student vs. mannequin arm) and time (preteaching, post, 90-days post). The dependent variables were test scores from the IV skills testing instrument, IV skills posttraining self-assessment survey, and 90-day postclinical self-assessment survey. A c 2 contingency test was used to test the effect of the variables (IV procedure practice on live students and practice using the rubber mannequin IV training arm) on the rates of peripheral IV cannulation success and failure. An analysis was conducted to determine whether or not there was a significant mean difference between the scores of the two groups performance of the procedure. In addition, nominal data and mean responses from the Likert scales in the surveys were compared using the c 2 contingency test, and in each case p < 0.05 was considered statistically significant. RESULTS There were 260 participants that initially consented to this study. One participant declined to continue in the study after the initial training phase was completed. Data analysis for the first phase therefore consisted of 259 participants. Fifty-seven (56.9%) percent had some college education but no degree, 26.2% were High School Graduates, 6.5% had Associates Degrees, 7.3% Bachelor s Degree, and 3.1% had a High School Graduate Equivalency Degree. A one-way analysis of variance was conducted to determine if education influenced the student s first attempt IV skills proficiency and no statistically significant difference was found in the first attempt pass rate between the groups. Because of academic attrition, subsequent analysis for the second phase of the study included data from 208 participants. There was no statistically significant difference ( p = 0.074) in the groups performance of the IV cannulation procedure on the first attempt, with 51.7% from the human arm group successfully completing the task, and 48.3% from the rubber mannequin group successfully completing the task. A one-way analysis of variance was conducted to further examine the effect of IV experience on initial IV administration pass rate. The results indicated no significant difference F(4,206) = 0.351, p = (Fig. 2). Response data from participants were also analyzed to determine if prior experience with medical simulators, that is, adult, infant, infusion arm, virtual reality, or any other simulation influenced the likelihood of success at the first attempt. The Spearman s rank correlation revealed no statistically significant correlation between first attempt pass frequencies and previous experience with any medical simulator (p > 0.05). Fear, anxiety, and preparedness were self-reported after training and again after the clinical rotation using a survey MILITARY MEDICINE, Vol. 179, November

6 FIGURE 2. Participant s medical and nonmedical experience versus first attempt pass rate. instrument with items scored on a four-point Likert scale. A Mann Whitney rank sum test was performed to analyze the relevant responses. The results showed that the human arm group reported significantly greater confidence after training (p = 0.015). The mean score in the human arm group was 3.02, SD = versus 2.79, SD = for the rubber mannequin arm group, where a higher score in this area indicates greater confidence. For the self-reported level of preparedness, the mean for the human arm group was 3.15, SD = and the mean for the rubber mannequin arm group was 2.96, SD = 0.800, where a higher score indicates greater self-reported preparedness. This result approached statistical significance ( p = 0.050). DISCUSSION The results of this study suggest that the adoption of part-task trainers such as the rubber mannequin IV training arms for teaching IV cannulation procedures may be helpful in the training of licensed practical nurses. In this study, no statistically significant difference was found in the performance of students on an objective assessment of IV cannulation skill between those who trained on the live human arm and those who trained on the rubber mannequin IV training arm. These data are consistent with other research concerning simulation. 8,11,13 Our results indicate that there was, however, a statistically significantly higher confidence level in the human arm group (p = 0.015). This may be the result of the confidence gained from successfully starting an IV on a peer. LIMITATIONS Although this investigational study provided opportunities for certified instructors to assess the IV skills of student nurses during the training and testing phase of the study, there was no mechanism to assess students IV skills during the 90-day evaluation phase of the study. Future research studies might focus on capturing data in this timeframe to assess the students abilities to perform the IV cannulation procedure after follow-up instruction in the live clinical environment. From a procedural standpoint, the standardized training video used as part of the students didactic instruction on IV cannulation was an Army training video created in Although the production of this video was dated, all of the skills covered in the video were compatible with contemporary procedures, with the exception of the covering of the IV site with gauze. This practice is no longer used because it obstructs the view of the IV site and prevents monitoring of the site for infiltration and infection. This change was emphasized with the students during the video. CONCLUSIONS The use of rubber mannequin IV arms to teach IV cannulation procedures to Army LPN students was shown in this study to have equivalent procedural skill outcomes to the more traditional method of having students insert IV s on fellow students. However, training on fellow students resulted in higher self-reported confidence in the live environment. Despite this, there was no significant difference between the groups in their IV skills performance on the first attempt during the initial training phase of the study. Thus, using the rubber mannequin IV training arm provided an equivalent mechanism to traditional methods for training students IV cannulation skills. Furthermore, the low-cost rubber IV arm provides an economical option without the percutaneous and infectious risks associated with practice on fellow students. More research should 1366 MILITARY MEDICINE, Vol. 179, November 2014

7 be done to support the use of the rubber mannequin IV training arm as an adjunct or primary method of IV training to build procedural knowledge and skill level and provide a safe environment for learning. ACKNOWLEDGMENTS The authors express their deepest appreciation to all the faculty and students of the Army Practical Nurse Course for their participation in this investigation. We also extend our gratitude to the staff of Brooke Army Medical Center s (BAMC) Simulation Center for their support and allowing us to use their equipment. REFERENCES 1. Army Training Requirements and Resources System (ATRRS): Prerequisites for Course 200-M6. Available at prerequisites.aspx?fy=2009&sch=081&crs=300-m6&phase=1&clsflag= (DA internal system); accessed April 23, National Association of Emergency Technicians: TCCC Guidelines and Curriculum: Skill Sheet Available at Libraries/PHTLS%20TCCC/020507%20Ruggedized%20Field%20IV% 20Skill%20Sheet% sflb; accessed April 23, Witting M: IV access difficulty: Incidence and delays in an urban emergency department. J Emerg Med 2012; 42: Department of Army: Training Circular (TC) Medical Education and Demonstration of Individual Competence (Medic). Washington, DC, Department of Army, May Available at (DA internal system); accessed April 23, Da Silva G, Priebe S, Dias F: Benefits of establishing an intravenous team and the standardization of peripheral intravenous catheters. J Infus Nurs 2010; 33: Anderson M, Bond M, Holmes T, Cason C: Acquisition of simulation skills: survey of users. Clin Simul Nurs 2012; 8(2): e59 e Schiavenato M: Reevaluating simulation in nursing education: beyond the human patient simulator. J Nurs Educ 2009; 48(7): Loukas C, Kikiteas N, Kanakis M, Georgiou E: Evaluating the effectiveness of virtual reality simulation training in intravenous cannulation. Simul Healthc 2011; 6(4): Reinhardt A, Mullins I, De Blieck C, Shultz P: IV insertion simulation: confidence, skill, and performance. Clinical Simulation in Nursing 2012; 8: e157 e Wilfong D, Falsetti D, McKinnon J, Daniel L, Wan Q: The effects of virtual intravenous and patient simulator training compared to the traditional approach of teaching nurses: a research project on peripheral IV catheter insertion. J Infus Nurs 2011; 34(1): Lund F, Schultz JH, Maatouk I, et al: Effectiveness of IV cannulation skills laboratory training and its transfer into clinical practice: a randomized, controlled trial. PLoS ONE 2012; 7(3), Sotto J, Ayuste E, Bowyer M, et al: Exporting simulation technology to the Philippines: a comparative study of traditional versus simulation methods for teaching intravenous cannulation. Stud Health Technol Inform 2009; 142: Acharya K, Weaver A, Li J, Tang X, Miquel-Verges F: Peripheral intravenous line skills among pediatrics and medicine-pediatrics residents at a single tertiary care center. Int J Med Educ 2013; 4: Texas State Board of Nursing: Position statements 15.3: LVNs engaging in intravenous therapy, venipuncture, or PICC lines, Available at accessed April 25, Jensen R: Teaching students about intravenous therapy: increased competence and confidence. J Assoc Vasc Access 2009; 14(1): Millam D: A study of I.V. therapy education. NITA 1985; 8(5): Laerdal: Adult IV Training Arm Manual, Gatesville, Texas, Medical Plastics Laboratory, MILITARY MEDICINE, Vol. 179, November